Medical Benefits Member Guide

Transcription

1 20 17 Medical Benefis Member Guide SEPTEMBER 1, 2016 AUGUST 31, 2017 THIS GUIDE IS FOR: Acive employees Reirees who are no eligible for Medicare HealhSelecSM of Texas (866)

2 Welcome HealhSelec SM of Texas is he sae s insurance plan available o employees, reirees, spouses and dependens who are eligible o paricipae in a Texas Employees Group Benefis Program (GBP) healh plan. Key informaion for Plan Year 2017: UniedHealhcare adminisers HealhSelec. The Employees Reiremen Sysem of Texas (ERS) ses he benefis and pays he claims, while UniedHealhcare manages he provider nework, processes claims and provides cusomer service. Caremark will adminiser he HealhSelec Prescripion Drug Program hrough December 31, As of January 1, 2017, OpumRx, an affiliae of UniedHealhcare, will become he hird-pary adminisraor of he prescripion drug program for HealhSelec of Texas. Call he HealhSelec Cusomer Care Team oll-free a (866) (TTY 711), 8 a.m. 7 p.m. CT, Monday Friday and 7 a.m. 3 p.m. CT on Saurday. Creae your personal online accoun o find ou if a provider is in he nework, access personal informaion abou your accoun and learn abou oher programs from UniedHealhcare. To learn more abou HealhSelec of Texas, visi Conens Your Plan Basics Wellness Programs and Services Key 2017 Benefis Online Resources Addiional Tips and Resources Key Terms...14 Please read his guide carefully. I will help you find wha you need, when you need i. For addiional informaion and resources menioned in his guide, visi Le s ge sared. 2

3 YOUR PLAN BASICS Ge off o a grea sar and learn he basics. Choose a nework docor, learn abou prevenive care, know where o find informaion and more. Provider Nework I Pays o Say in he Nework The UniedHealhcare provider nework includes more han 58,250 docors in Texas and 851,000 naionwide. You will pay less if you use a nework provider. Find ou if a provider is in he nework a Designaing a Primary Care Physician (PCP) I is imporan o choose a PCP, because he or she will help you mainain your overall healh and issue referrals for specialy care. To designae a PCP, call oll-free a (866) (TTY 711). Choosing Your Docors wih Confidence Our nework docors have been carefully evaluaed o help you selec he righ docor. UniedHealhcare idenifies many nework providers as Premiumdesignaed or Tier 1 providers. The UniedHealh Premium designaion program recognizes physicians who mee naional indusry sandards for qualiy care and local marke benchmarks for cos-efficiency. You can find Premium-designaed (Tier 1) docors on Remember, you will pay less ou of pocke when you use nework docors! How o Find a Nework Physician or Hospial 1. Go o 2. Click Find a Docor or Hospial. 3. Click Find a Physician Near You o search for a nework provider. or 4. Click Find a Faciliy Near You o search for a nework hospial. Prevenive Services Covered a 100% Prevenive care can help you say healhy. When you use a nework provider, you have many prevenive care benefis, including: Rouine checkups Screenings Immunizaions Prenaal care Well-woman visis Domesic violence screenings Conracepion approved by he Food and Drug Adminisraion Under he Affordable Care Ac (ACA), cerain prevenive healh and women s services are paid a 100% (a no cos o he paricipan) based on physician billing and diagnosis. In some cases, you may be responsible for paymen on cerain relaed services ha are no required o be paid a 100% by he ACA. Visi for prevenive care guidelines and a checklis o use wih your docor. 3

4 Healh RUN_DATE DATA_SEQ_NO CLIENT_NUMBER UHG_TYPE DOC_ID DOC_SEQ_ID NAME MAILSET_NUMBER CUSTCES_KEY _KEY0 CUSTCES_KEY2 CUSTCES_KEY3 CUSTCES_KEY4 CUSTCES_KEY5 CUSTCES_KEY6 CUSTCES_KEY7 CUSTCES_KEY8 CUSTCES_KEY9 Plan SMITH (80840) DIG2SHRT SPOUSE SUBSCRIBER HCAC/Medical ~01CARD ~00CARD ~01CARD ~00CARD :52:35,SUBSCRIBER Member ID: Group Number: : ER ical 001~01CARD1 001~00CARD2 9~01CARD1 9~00CARD2 Member:,SUBSCRIBER This card does 3/3 no guaranee coverage. To HealhSelec of Texas SPOUSE SMITH provider; visi he websies or call. Referrals For Members: Prined: 06/08/15 PCP: Prined: 06/08/15 FIRSTNAME LASTNAME Payer ID T USE SCRIBER C/Medical ~01CARD ~00CARD ~01CARD ~00CARD2 10:52:35 PCP Phone: (999) ,SUBSCRIBER /3 ealh Plan (80840) Eff D Always Carry Your Medical ID Card ember ID: Healh Plan (80840) Group Number: 06/08/ For Providers: Copays: Your Go-o Prined: App 06/08/15 ember: Member ID: Group Number: This card does no guaranee coverage. To verify benefis, view claims, or find a Your Office: medical $25 ID ER: card $150 has HealhSelec key informaion of Texas abou you and your coverage Keep 3/3 Medical Claims: PO BOX R 2SHRT ER KEY0 POUSE SPOUSE SUBSCRIBER HCAC/Medical ~01CARD ~00CARD ~01CARD ~00CARD SMITH provider; Member: 10:52:35,SUBSCRIBER This visicard he does websies no guaranee or call. Referrals for Healh coverage. required To verify forbenefis, cerain services. view claims, or find a your UrgCare: card $50 in your Spec: walle, $40 your pockebook HealhSelec of Texas SPOUSE SMITH or your purse so you won For forge Members: provider; i. visi he websies or call. Referrals required for cerain CP: services. Healh Plan (80840) IRSTNAMEPCP: LASTNAME For Members: Member ID: GroupPayer Number: ID CP Phone: FIRSTNAME (999) LASTNAME Show Member: your medical ID card o your providers, Payer so IDha 87726hey can updae This card does heir no HealhSelec of Texas 3/3 guaranee coverage. To verify benefis, view claims, or find a PCP Phone: (999) Eff D SPOUSE SMITH provider; visi he websies or call. Referrals required for cerain services. 06/08/2015 Eff D UniedHealhcare Navigae Plus records and know how o bill for he services hey are providing For o Members: you. The Healh4Me opays: 0501 PCP: 06/08/2015 Adminisered by [Appropriae Legal For Providers: Prined: Eniy] 06/08/15 Copays: FIRSTNAME LASTNAME Payer ID Medical For Claims: Providers: PO BOX Alana, GA ffice: $25 ER: $150 PCP Phone: (999) Medical Claims: app PO BOX for smarphones Alana, provides GA rgcare: $50 Office: Spec: $25$40 ER: $150 Eff D UrgCare: $50 Spec: $40 06/08/2015 For Providers: Copays: Prined: 06/08/15 insan access o criical Medical Claims: PO BOX Alana, GA You ll Office: $25 need ER: hese $150 UrgCare: $50 Spec: $40 healh informaion numbers when you UniedHealhcare call Navigae Plus 501 Adminisered UniedHealhcare by [Appropriae Legal Navigae Eniy] Plus 0501 o alk wih a cusomer This card does no Adminisered guaranee coverage. by [Appropriae To verify Legal benefis, Eniy] view claims, Prined: or find 06/08/15 a UniedHealhcare Navigae Plus Key feaures include he abiliy o: up Number: care 0501 professional Adminisered by [Appropriae Legal Eniy] Healh provider; visi he websies or call. Referrals required for cerain services. Plan (80840) For Members: This card does no guaranee coverage. To verify benefis, view claims, or find a Prined: 06/08/ Search for nework physicians Prined: 06/08/15 c of Texas provider; visi he websies or call. Referrals required for cerain services. Prined: 06/08/ Member ID: Group Number: For Members: Group Number: or faciliies This card does no guaranee coverage. To verify benefis, view claims, or find a HealhSelec of Texas Member: This card does no guaranee coverage. To Payer ID provider; visi he websies or call. Referrals required for cerain services. ealh Plan (80840) Healh SUBSCRIBER Healh Plan Plan (80840) (80840) SMITH For Providers: HealhSelec of Texas For Members: View provider; claims and visi benefi he websies or call. Referrals ember ID: Member ID: Medical Claims: Group PONumber: BOX Alana, GA Member PCP: Payer IDID: Group For Providers: Number: Group Number: For Members: plan deails Member: This card does no guaranee coverage. To verify benefis, view claims, or find a D Medical HealhSelec Claims: of Texas PO BOX Alana, GA 08/2015 ember: SUBSCRIBER SMITH provider; visi he websies or call. Referrals required for cerain services. Member: FIRSTNAME LASTNAME This cardthis does card no does guaranee no guaranee coverage. coverage. To verify To benefis, verify benefis, view claims, view claims, or find orafind a PCP: HealhSelec For HealhSelec of Providers: Texas of Texas Payer ID For Members: Check UBSCRIBER SUBSCRIBER PCP SMITHPhone: SMITH (999) provider; provider; visi hevisi websies he websies or call. or Referrals call. Referrals saus required required of for deducible cerain for cerain services. services. and FIRSTNAME LASTNAME Medical Claims: PO BOX Alana, GA CP: PCP: Payer ID For Members: For Members: igae Plus Eff D PCP Phone: (999) ou-of-pocke spending IRSTNAMEFIRSTNAME LASTNAME LASTNAME Eff D ealhcare Legal Eniy] Navigae Plus 06/08/ /08/2015 Payer IDPayer 87726ID CP Phone: PCP (999) Copays: Phone: For Providers: For Providers: red by [Appropriae Legal Copays: Eniy] (999) UniedHealhcare Navigae Plus Medical Claims: PO BOX Alana, View GA your medical ID card ER: $150 Eff D Eff D Medical Claims: PO BOX Adminisered by [Appropriae Office: $25 UrgCare: Legal Eniy] ER: $150 Spec: 06/08/2015 $40 06/08/2015 Prined: For Providers: opays: Copays: UrgCare: $50 Spec: $40 For 06/08/15 Providers: Prined: 06/08/15 Medical Claims: POConnec BOX wih Alana, HealhSelec GA ffice: $25 Office: ER: $25 $150 ER: $150 Medical Claims: PO BOX Alana, GA Prined: 06/08/15 rgcare: $50 UrgCare: Spec: $50 Spec: $40 UniedHealhcare Navigae Plus Cusomer Care 0501 $40 Adminisered by [Appropriae Legal Eniy] 6-04 UniedHealhcare Navigae Plus Download Healh4Me from he up Number: 0501 UniedHealhcare Navigae Plus Group Number: Your copay for UniedHealhcare AdminiseredNavigae Adminisered by [Appropriae Plusby [Appropriae Legal Eniy] Legal Eniy] App Sore or Google Play 501 Adminisered This This card card by does [Appropriae does no no guaranee Legal coverage. Eniy] To Toverify verify benefis, benefis, view view claims, findor a find a c HealhSelec of Texas of Texasa medical visi This card does no guaranee coverage. To verify benefis, view claims, or a provider; visi heprovider; websies visi visi he he or websies call. Referrals or call. Referrals required required required for cerain for for cerain services. services. (if applicable Shipper ID: o For Members: For For Members: Inser #1 Inser #2 your Shipping plan) Mehod: 2ND DAY Inser #3 Inser #4 Payer ID Payer ID D CARRIER: UPS Inser #5 Inser #6 08/2015 Address: For Providers: Inser #7 Inser #8 ForMedical Providers: TO: UniedHealhcare Claims: PO BOX Alana, GA Inser For Providers: Medicalwww.UniedHealhcareOnline.com Claims: PO BOX Alana, GA #9 Inser #10 UniedHealhcare Inser #11 Inser #12 as Shipper ID: Inser #1 Shipper ID: Medical Claims: PO BOX Alana, GA Inser #1 Inser #2 Inser #2 Shipping Mehod: 2ND DAY Inser #3 Inser #4 UniedHealhcare Navigae Plus Adminisered CARRIER: by [Appropriae UPSLegal Eniy] ealhcare Navigae Plus Inser #5 Inser #6 red by [Appropriae Legal Eniy] igae Address: Plus Inser #7 Inser #8 Legal Eniy] TO: UniedHealhcare Inser #9 Inser #10 UniedHealhcare Inser #11 Inser #12 ATTN: HealhSelec of Texas AY P.O. Box Inser #3 Inser #4 Cycle Dae: San Anonio, TX PDF Dae: Tue Jun 09, 10:52:35 Shipping Shipper ATTN: Mehod: HealhSelec ID: ND of Texas DAY Inser #3 Inser #1 Inser #4 In CARRIER: Shipping P.O. BoxUPS Mehod: 2ND DAY Cycle Dae: Inser #5 Inser #3 Inser #6 In Address: San Anonio, TX PDF Dae: Tue Inser Jun 09, 10:52:35 Inser #8 CARRIER: UPS MaxMover: N Inser #5 In TO: UniedHealhcare Mailing/Meer Dae: Visi his websie for Call his UHG number JOB ID: o Inser #9 Inser # GRP: PV: 0001 RC: 0001 MKT: UniedHealhcare Address: benefi and wellness alk o a MT: cusomer 15 SA: 00 Inser OI: 01#11 Inser #7 FORM: K20007 CPAY: B INTL ID: Inser #12 In ATTN: TO: HealhSelec UniedHealhcare of Texas informaion care professional DALE BROWN: NO LTR: TXERS2015 STOCK Inser ID : STAN Healh4Me #9 In P.O. Box Inser #1 Inser #2 UniedHealhcare TEMPLATE: Cycle NEW FAMILY/IND Dae: : STD IND Inser : 2SHRT :#11 2SHRT In San Anonio, TX 78229Inser #5 #6 RSN CD: ATTN: HealhSelec #1 of Texas Inser #2 PDF Dae: Tue Jun 09, 10:52:35 Inser Inser #3 #7 Inser #8#4 MaxMover: N Inser #9 #10 Mailing/Meer P.O. Inser Box Dae: #1 Inser #5 Inser Inser #2 #6 MaxMover: UHG JOB N ID: 9210 GRP: Cycle Dae: PV: RC: 0001 MKT: Inser #11 Inser #12 San Anonio, Inser #3 Inser TX #7 Inser Inser #4 #8 MT: 15 SA: 00 OI: 01 FORM: PDF Dae: K20007Tue CPAY: Jun B INTL 09, ID: 10:52: Need a Temporary Inser #5 Inser #9 Cycle Medical Dae: ID Card? Inser Inser #6 #10 MT: 15DALE SA: 00 BROWN: OI: 01 FORM: NO LTR: MaxMover: K20007 TXERS2015 CPAY: NSTOCK B INTLID ID: : STAN Mailing/Meer Dae: UHG JOB ID: 9210 GRP: PV: 0001 RC: 0001 MKT: Inser #11 Inser #12 Inser #7 PDF Dae: Tue Jun 09, Inser 10:52:35 #8 If you Mailing/Meer los your Inser medical #9 Dae: ID MaxMover: card or Nare waiing o Inser receive #10 DALE TEMPLATE: BROWN: NONEW LTR: FAMILY/IND TXERS2015 i in he mail, you can UHG JOB : STD STOCK ID: IND 9210 : ID 2SHRT : STAN GRP: : 2SHRT PV: Inser #11Cycle UHG Dae: JOB ID: GRP: Inser PV: # RC: 0001TEMPLATE: MKT: RSN CD: NEW FAMILY/IND : STD IND : 2SHRT : 2SHRT prin a emporary card PDF o MT: Dae: use 15 SA: unil Tue 00Jun you OI: 01 09, receive FORM: K20007 a 10:52:35 permanen CPAY: B INTL replacemen. ID: Go MT: 15 SA: 00 OI: 01 FORM: K20007 C o MaxMover: DALE log BROWN: ino N RSN CD: your NO LTR: personal TXERS2015 accoun STOCKand ID : STAN click Prin an ID Cycle Dae: DALE BROWN: NO LTR: TXERS2015 Card. Remember, you UHG can TEMPLATE: JOB always ID: 9210 NEW view GRP: FAMILY/IND your medical : STD PV: IND 0001 ID : 2SHRT card RC: : on SHRT he MKT: Healh4Me PDF Dae: Tue Jun 09, 10:52:35 MT: RSN 15 SA: CD: 00 OI: 01 FORM: K20007 CPAY: B INTL ID: TEMPLATE: NEW FAMILY/IND : STD I app for smarphones. MaxMover: N DALE BROWN: NO LTR: TXERS2015 STOCK ID : STAN RSN CD: UHG JOB TEMPLATE: ID: 9210 GRP: NEW FAMILY/IND PV: : 0001 STD IND RC: : 2SHRT 0001 MKT: : 2SHRT MT: 15 SA: 00 OI: 01 FORM: K20007 CPAY: B INTL ID: RSN CD: DALE BROWN: NO LTR: TXERS2015 STOCK ID : STAN TEMPLATE: NEW FAMILY/IND : STD IND : 2SHRT : 2SHRT RSN CD: 4

5 Your Privae Online Accoun You can creae a personal accoun where you can see your own claims hisory and use various ools. To se up your personal online accoun, go o You will need informaion from your medical ID card. Once you regiser and log ino your personal accoun a you can: Find ou if a provider or hospial is in he nework View your claims and claims hisory Conac a Nurse Advocae View referrals given by your PCP Your healh plan name and numbers Access healh and wellness informaion and programs, like Rally Ge healh and vision produc discouns Quick access o useful ools Learn Abou he HealhSelec Benefi Plan a Learn abou your covered medical benefis Find a nework docor or hospial in your area Look up healh and wellness educaion resources Review news and updaes See Plan Year 2017 Maser Benefi Plan Documen (MBPD) Link o a member websie a Informaion abou new services Educaional websies Quick access o a nurse 5

6 WELLNESS PROGR AMS AND SERVICES Ge involved in your healh care decisions. Use hese complimenary ools and resources o help mainain and improve your healh. To learn more, call oll-free a (866) or go o Lose Weigh wih Real Appeal Real Appeal is an online weigh loss program ha can help you develop healhy habis o lose weigh and keep i off. Wheher you wan o drop a few pounds or make a more significan change, Real Appeal may be able o help you reach your weigh-loss goals and lead a healhier life. Real Appeal is available a no cos o eligible HealhSelec of Texas paricipans and dependens 18 and older (excludes Medicare primary paricipans) wih a body mass index (BMI) of 23 or higher. For more informaion or o enroll, visi healhselec.realappeal.com. Your Nurse Advocae: Ge Trused Informaion* Regisered nurses and maser s-level specialiss can help you anyime wih: Sympoms and reamen opions Docors and hospials Healh condiion managemen and more You can reach a regisered nurse oll-free a (866) simply say speak wih a nurse. Ge Suppor for a Chronic Condiion Nurse advocaes* can also provide resources for managing a chronic condiion. A chronic condiion may seem overwhelming and a imes hard o manage. To help you, we offer many Disease Managemen programs ha provide personalized suppor for he following condiions: Hear Failure Ashma Coronary Arery Disease (CAD) Chronic Obsrucive Pulmonary Disease (COPD) Diabees 6

7 Make an Informed Choice Abou Your Treamen Our Treamen Decision Suppor gives you access o specially rained regisered nurses* jus call oll-free a (866) and say speak wih a nurse. They can answer your quesions and help you make an informed choice abou your reamen opions for services relaed o hese condiions: Coronary disease Breas cancer Chronic back pain Benign uerine condiion Hip or knee replacemen Endomeriosis Benign prosae disease Fibroids Prosae cancer Enroll in a Healh Coaching Program* Our Wellness Coaching programs suppor individuals ineresed in: Diabees Sress Managemen Exercise Tobacco Cessaion Hear Healh Weigh Managemen Nuriion Save on Wellness and Vision Producs and Services Enjoy a healhy lifesyle for less, wih our discouned healh and vision producs and services. Ge discouns on finess club memberships, weigh loss programs, glasses, conac lenses, laser vision correcion and more. Access our healh discoun program** a Our wellness coaches are experienced wellness consulans. They can help you se your goals and creae a personalized plan o help you mee hem. Members ge assigned o one wellness coach a he beginning of heir program and keep he same coach hroughou heir program. If you are dealing wih more han one issue, you can enroll yourself in muliple programs and receive unlimied elephone coaching or informaion hrough he mail. We have mulilingual coaching, including Spanish-speaking coaches. To learn more, call oll-free a (866) Receive Personalized Guidance Throughou Your Pregnancy The Healhy Pregnancy program helps expecan mohers hrough every sage of pregnancy and delivery. The program offers 24-hour access o experienced nurses, he online Healhy Pregnancy Owner s Manual and oher maerials, as well as complimenary gifs (subjec o availabiliy). To enroll, call oll-free a (888) * This service should no be used for emergency or urgen care needs. In an emergency, call 911 or go o he neares emergency room. The informaion provided hrough he program is for informaional purposes only and provided as par of your healh plan. Wellness nurses, coaches and oher represenaives canno diagnose problems or recommend reamen and are no a subsiue for your docor s care. Your healh informaion is kep confidenial in accordance wih he law. The program is no an insurance program and may be disconinued a any ime. ** The healh discoun program is no insurance. 7

8 KEY 2017 BENEFITS Plan Overview In-Area Nework Non-Nework Ou-of-Area (for ou-of-sae residens) Coinsurance (per paricipan) Inpaien copaymen maximum (per paricipan) Deducible (per paricipan/family) $2,000/per paricipan only $7,000/per paricipan only $3,000/per paricipan only $2,250 $2,250 $2,250 $0 $500/$1,500 $200/$600 TOTAL ANNUAL OUT-OF-POCKET MAXIMUM (per paricipan/family; includes copaymens for medical services and prescripion medicaions, deducibles and coinsurance) Effecive January 1, 2016: $6,450 per paricipan, $12,900 per family Effecive January 1, 2017: $6,550 per paricipan, $13,100 per family None Effecive January 1, 2016: $6,450 per paricipan, $12,900 per family Effecive January 1, 2017: $6,550 per paricipan, $13,100 per family Lifeime maximum None None None Primary care physician (PCP) required Yes No No Plan Deails In-Area Nework Non-Nework Ou-of-Area (for ou-of-sae residens) PCP office visi $25 copay 40% coinsurance 30% coinsurance Specialis office visi Be sure o ge a referral from your PCP o avoid possible ou-of-pocke coss. Rouine physicals* (including vision screenings for children) and well-woman exams* $40 copay $0 40% coinsurance $0 if services are in-nework Virual visis $10 copay No covered 30% coinsurance if services are in-nework Convenience care clinic (no PCP referral required) Urgen care clinic (no PCP referral required) $25 copay 40% coinsurance 30% coinsurance $50 copay + 20% coinsurance Eye exams (no PCP referral required) Rouine exams are limied o one exam per year. $40 specialis copay + 20% coinsurance for lab or radiology done ouside office visi 40% coinsurance 30% coinsurance Maerniy care* Physician charges only, including delivery fees; inpaien hospial copay benefi applies for he inpaien say (complicaions of pregnancy are reaed as any oher medical condiion) Office surgery and diagnosic procedures Allergy anigens/serum Allergy injecions Allergy esing $0 (rouine prenaal obserical office visis) 20% coinsurance (office surgery) $0 (office diagnosics) $0 (office-based allergy services) 40% coinsurance $0 for rouine prenaal obserical office visis if services are in-nework 40% coinsurance 30% coinsurance DME (Durable Medical Equipmen) (3-year replacemen limi) Prior Auhorizaion required for DME over $1, % coinsurance 40% coinsurance 30% coinsurance * Under he Affordable Care Ac, cerain prevenive and women s healh services are paid a 100% (a no cos o he paricipan) based on physician billing and diagnosis. In some cases, you will sill be responsible for paymen on some services. 8

9 HealhSelecSM of Texas Plan Deails In-Area Nework Non-Nework Ou-of-Area (for ou-of-sae residens) Diabeic supplies 20% coinsurance 20% coinsurance 30% coinsurance Diagnosic low-ech radiology X-rays Mammography Bone densiy scan Echocardiogram Ulrasound $0 (for office-based services) 20% coinsurance (for non-office based services) 40% coinsurance 30% coinsurance High-ech radiology CT scan MRI Nuclear medicine You will be responsible for he copay (if applicable) and coinsurance per visi. Prior Auhorizaion required. $100 copay + 20% coinsurance $100 copay + 40% coinsurance $100 copay + 30% coinsurance Chiropracic care (benefi maximum of $75 per visi and maximum 30 visis per calendar year, per paricipan) You pay $40 specialis copay and/or 20% coinsurance in addiion o amouns above he benefi maximum 40% coinsurance, afer deducible, plus amoun over benefi maximum 30% coinsurance, afer deducible, plus amoun over benefi maximum Inpaien hospial (faciliy charges per admission, $750 copay maximum per admission, $2,250 calendar year inpaien copay max per paricipan) $150 copay per day up o five days + 20% coinsurance $150 copay per day up o five days + 40% coinsurance $150 copay per day up o five days + 30% coinsurance Prior Auhorizaion required. Inpaien physician (per admission) You may have o pay addiional coss if reaed by a non-nework physician during your hospial say. 20% coinsurance 40% coinsurance 30% coinsurance Emergency room In a non-emergency siuaion, consider less expensive opions, such as a convenience care clinic or urgen care clinic. $150 copay + 20% coinsurance (copay waived if admied) $150 copay + 20% coinsurance (copay waived if admied) 30% coinsurance Oupaien day-surgery Faciliy (faciliy charges) Oupaien day-surgery Physician (physician charges) $100 copay + 20% coinsurance $100 copay + 40% coinsurance $100 copay + 30% coinsurance 20% coinsurance 40% coinsurance 30% coinsurance Hearing aids Plan pays up o $1,000 maximum benefi (per ear) for any consecuive hree-year (36-monh) period. $0 (plus any amoun over he benefi maximum) $0 (plus any amoun over he benefi maximum) $0 (plus any amoun over he benefi maximum) Ambulance services (Prior Auhorizaion required for non-emergen air) 20% coinsurance 20% coinsurance 30% coinsurance Menal healh and subsance use disorder Hospial Inpaien say (copay is $150 per day, up o a maximum of $750 per admission and a maximum of $2,250 per calendar year) Oupaien faciliy care (parial hospializaion/day reamen and inensive oupaien reamen) 20% coinsurance afer you pay he copay 40% coinsurance afer you pay he copay and afer you mee he annual Non-Nework Deducible 20% coinsurance 40% coinsurance afer you mee he annual Non-Nework Deducible Oupaien physician or menal healh provider services $25 copay 40% coinsurance afer you mee he annual Non-Nework Deducible 30% coinsurance afer you pay he copay and afer you mee he annual Ou-of-Area Deducible 30% coinsurance afer you mee he annual Ou-of-Area Deducible 30% coinsurance afer you mee he annual Ou-of-Area Deducible The chars on hese wo pages include ou-of-pocke coss for common services. For deailed informaion abou benefis, limiaions and exclusions, refer o he Maser Benefi Plan Documen (MBPD) under he Publicaions and Forms ab a on or afer Sepember 1,

10 ONLINE RESOURCES Use hese addiional complimenary resources o ge educaional informaion online a Virual Docor Visis Now you can see a docor wihou leaving your home or office wih he new virual docor visi benefi available o HealhSelec plan members and covered dependens. A virual visi is a convenien care opion when your docor is unavailable, when you become ill while raveling, or as an alernaive o he emergency room or urgen care for non-emergency healh issues. Here s how i works: You mus use nework providers for services o be covered. Mee wih a licensed virual visi nework provider from your compuer or mobile device using secure online audio and video echnology. Virual visi providers can diagnose and rea a wide range of medical condiions such as sinus problems, sore hroa, pink eye, bronchiis and more. Mos virual visis ake 10 o 15 minues and he service is available 24 hours a day, including weekends and holidays. A docor is generally available wihin 30 minues of your reques, or you can schedule an appoinmen. If needed, virual visi docors can wrie an elecronic prescripion for pick up a your local pharmacy. Prescripion services are currenly available in Texas bu may no be available in oher saes. Afer locaing and regisering wih a nework provider and requesing a visi, you pay your porion of he cos wih a credi or debi card. To locae a nework virual visi provider or for more informaion, log in o your personal online accoun a and click on he Virual Visis link. In-Area* Virual Visi Member Healh Cos Ou-of-Area* $10 copay 30% coinsurance afer you mee he ou-of-area deducible of $200 person/$600 family * Services delivered by non-nework providers are no covered. 10

11 Healh Care Lane Visi exas for informaion abou healh and wellness opics. Make sure o check ou Wellness Days, a fun-filled online fesival of good healh and wellness. Healhy Mind Healhy Body Newsleer Our award-winning Healhy Mind Healhy Body online publicaion provides he laes healh news and ips, and allows you o selec healh opics ha mee your personal needs and ineress. Topics range from family healh and finess, o diabees and ashma managemen. Sign up a Reach Your Healh Goals wih Rally Rally is a new ineracive healh experience on I can help you ge healhier one small sep a a ime. I shows you how o make simple changes o your daily rouine and moivaes you along he way. Take he Rally Healh Survey o ge an immediae, confidenial assessmen of your overall healh compared o your acual age called your Rally Age SM. Choose from recommended Missions simple hings you can do o improve your healh, such as focus on fruis and veggies or read for 20 minues. Sep up o a Rally Healh Challenge o help you reach your healh goals. Earn Rally Coins for your effors and use hem o conribue o seleced chariies. Your coins will be combined wih hose of oher Rally users o reach a cerain goal. When he goal is reached, Rally will make a moneary conribuion o ha organizaion. You can rack up Rally Coins for joining Missions, pushing yourself in a challenge and even jus for logging in each day. To ge sared, log ino your personal online accoun a 11

12 ADDITIONAL TIPS AND RESOURCES Learn more abou your care opions, referrals, Prior Auhorizaions and delivery opions for your healh documens. Where o Go When You Are Sick or Injured For mos medical problems, you should ry o go o your regular healh care provider firs. Bu if your docor is no available, he char below can help you choose he righ place for care for your siuaion. You can alk o a nurse o help you decide where o go for care call anyime oll-free a (866) (simply say speak wih a nurse ). Remember, in a rue emergency, i is always bes o call 911. Care cener Docor s Office Why would I use his care cener? You need rouine care or reamen for a curren healh issue. Your docor knows your healh hisory, can access your medical records, provide prevenive and rouine care, manage your medicaions and refer you o a specialis, if necessary. Wha ype of care would hey provide? 1 Rouine checkups Immunizaions Prevenive services Help you manage your general healh Wha are he cos and ime consideraions? 2 Ofen requires a copaymen and/or coinsurance Normally requires an appoinmen Scheduled appoinmens can help reduce wai ime Virual Visi Convenience Care Clinic 3 You wan a convenien way o speak wih a docor abou a non-urgen condiion wihou leaving your home or work place. A virual visi les you see and alk o a docor in he virual provider nework from your mobile device or compuer when you need non-emergency medical aenion. No appoinmen or referral is needed. You can ge o your docor s office, bu your condiion is no urgen or an emergency. Convenience care clinics are ypically locaed in many reail sores offering services for minor healh condiions. Saffed by nurse praciioners and physician assisans. Bladder infecion/ urinary rac infecion Bronchiis Cold/flu Diarrhea Fever Migraine/headaches Pink eye Rash Sinus problems Sore hroa Somachache Common infecions (for example, srep hroa) Minor skin condiions (for example, poison ivy) Flu shos Pregnancy ess Minor cus Earaches Ofen requires a copaymen and/or coinsurance ha is less han an office visi Virual visi providers are expeced o deliver care wihin 30 minues or less from he ime of he paien s reques Paiens can also make an appoinmen for anoher ime wih a virual visi docor Ofen requires a copaymen and/or coinsurance similar o office visi Walk-in paiens welcome wih no appoinmens necessary, bu wai imes can vary Urgen Care Cener 3 You may need care quickly, bu i is no an emergency, and your docor may no be available. Urgen care ceners offer reamen for non-life hreaening injuries or illnesses. Saffed by qualified physicians. Sprains Srains Minor broken bones (for example, a finger) Minor infecions Minor burns Ofen a less cosly alernaive o he emergency room Walk-in paiens welcome, bu waiing periods may be longer as paiens wih more urgen needs will be reaed firs Emergency Room (ER) You need immediae reamen of a very serious or criical condiion. The ER is for he reamen of life-hreaening or very serious condiions ha require immediae medical aenion. Do no ignore an emergency. If a siuaion seems life-hreaening, ake acion. Call 911 or your local emergency number righ away. Heavy bleeding Large open wounds Sudden change in vision Ches pain Sudden weakness or rouble alking Major burns Spinal injuries Severe head injury Difficuly breahing Major broken bones Requires a much higher copaymen and/or coinsurance Open 24/7, bu waiing periods may be long based on he number of paiens 1 This is a sample lis of services and may no be all-inclusive. 2 Coss and ime informaion represen averages only and are no ied o a specific condiion or reamen. Your ou-of-pocke coss will vary based on plan design. 3 Convenience Care Clinics and Urgen Care Ceners may no be available where you live. 12

13 Referrals for Specialy Care If your visi requires a referral, your PCP will need o submi he referral reques o UniedHealhcare prior o your appoinmen. You can verify wih your PCP and/or HealhSelec Cusomer Care ha you have a referral. New referrals are valid for up o 12 monhs or up o 12 visis (whichever occurs firs). You will need o discuss addiional referrals wih your PCP, if hey are needed. Cerain chronic condiions, such as cancer or allergy reamen, may be eligible for a sanding referral which is valid for up o 12 monhs. Referrals from your PCP are no required for he following services: eye exams, OB/GYN visis, behavioral healh counseling, oupaien herapies (including chiropracic visis), virual visis, urgen care ceners and convenience care clinics. Prior Auhorizaions for Cerain Healh Services Cerain healh services like inpaien hospial says, skilled nursing services, home healh services and durable medical equipmen over $1,000 mus be pre-auhorized. When you use a nework provider, ha provider will be responsible for obaining any Prior Auhorizaions required by he plan. Ongoing reamens including oupaien rehabiliaion herapies, such as physical herapy or occupaional herapy, durable medical equipmen and chiropracic reamen, mus be considered medically necessary and would require he provider o submi a reamen plan. These requiremens are in addiion o any referrals from your PCP o specialiss. Thank You for Going Green wih Us HealhSelec paricipans auomaically receive heir Explanaion of Benefis (EOB), healh saemens and claim leers online. An is sen o you when your documens are ready for viewing. Remember, an EOB is no a bill. Should you desire mail delivery, you can reques prined versions of hese documens jus call oll-free a (866) and ask o change your communicaion preferences from online o paper delivery. For illusraive purposes sample only 13

14 KEY TERMS Benefis: Medical iems and healh services ha are covered under he HealhSelec plan. Coinsurance: The percenage of he cos ha you have o pay for covered healh services afer you have paid any applicable deducibles and copaymens. Copaymens: The se dollar amoun you pay for a docor visi, hospial say or oher covered healh service. Deducibles: The se dollar amoun ha you pay before he HealhSelec plan sars o pay for covered benefis, if applicable o your covered benefis. Healh saemen: A documen showing monhly claim aciviy and coss for all family members covered on your plan. I shows nework and non-nework informaion, as well as remaining balances for deducibles and ou-of-pocke coss. Maser Benefi Plan Documen (MBPD): A descripion of he benefis included in your plan. Medical ID card: The card issued o you by UniedHealhcare ha includes your name, group and policy informaion, and imporan phone numbers, such as Cusomer Care. Nework provider: Docors, hospials, nursing homes, laboraories and oher providers ha have conracs wih UniedHealhcare. Someimes called in-nework provider or paricipaing nework provider. You will pay more for services provided by non-nework providers. Non-nework provider: Docors, hospials and oher providers ha do no paricipae in he UniedHealhcare nework. Their services cos you more. Someimes called ou-of-nework provider or non-paricipaing nework provider. Ou-of-pocke coss: The coss for healh services ha are your responsibiliy. Ou-of-pocke maximum: The mos you have o pay for covered healh services during he calendar year. Ou-of-pocke maximum includes deducible, coinsurance and copaymens, if applicable. Primary care physician (PCP): This is he docor you go o firs when you are no feeling well. A PCP can be an Inernis, OB/Gyn, Family Docor or oher provider lised in he PCP secion of he Provider Direcory and online Provider Search Tool a To see a complee Glossary of Healh Coverage and Medical Terms, go o Publicaions and Forms ab. 14

15 UniedHealhcare Services, Inc., on behalf of iself and is affiliaed companies, complies wih applicable Federal civil righs laws and does no discriminae on he basis of race, color, naional origin, age, disabiliy or sex. UniedHealhcare does no exclude people or rea hem differenly because of race, color, naional origin, age, disabiliy or sex. UniedHealhcare provides free aids and services o people wih disabiliies o communicae effecively wih us, such as: Qualified sign language inerpreers Wrien informaion in oher formas (large prin, audio, accessible elecronic formas, oher formas) Provides free language services o people whose primary language is no English, such as qualified inerpreers Informaion wrien in oher languages If you need hese services, please call oll-free (866) (TTY 711), Monday hrough Friday, 8 a.m. o 7 p.m. CT and Saurday, 7 a.m. o 3 p.m. CT. If you believe ha he Company has failed o provide hese services or discriminaed in anoher way on he basis of race, color, naional origin, age, disabiliy or sex, you can file a grievance in wriing by mail or . A grievance mus be sen wihin 60 calendar days of he dae ha you become aware of he discriminaory acion and conain he name and address of he person filing i along wih he problem and he requesed remedy. A wrien decision will be sen o you wihin 30 calendar days. If you disagree wih he decision, you may file an appeal wihin 15 calendar days of receiving he decision. Civil Righs Coordinaor P.O. Box Sal Lake Ciy, UT UHC_Civil_Righs@UHC.com If you need help filing a grievance, please call oll-free (866) (TTY 711), Monday hrough Friday, 8 a.m. o 7 p.m. CT and Saurday, 7 a.m. o 3 p.m. CT. You can also file a complain direcly wih he U.S. Dep. of Healh and Human services online, by phone or mail: Online: hps://ocrporal.hhs.gov/ocr/poral/lobby.jsf Complain forms are available a: hp:// Phone: Toll-free (800) , (800) (TDD) Mail: U.S. Dep. of Healh and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building, Washingon, D.C You have he righ o ge help and informaion in your language a no cos. To reques an inerpreer, please call oll-free (866) (TTY 711), Monday hrough Friday, 8 a.m. o 7 p.m. CT and Saurday, 7 a.m. o 3 p.m. CT. This leer is also available in oher formas like large prin. To reques he documen in anoher forma, please call oll-free (866) (TTY 711), Monday hrough Friday, 8 a.m. o 7 p.m. CT and Saurday, 7 a.m. o 3 p.m. CT. 15

16 16 Tiene derecho a recibir ayuda e información en su idioma sin coso. Para soliciar un inérpree, llame al número de eléfono grauio para miembros que se encuenra en su arjea de idenificación del plan de salud y presione (866) TTY 711 Quý vị có quyền được giúp đỡ và cấp hông in bằng ngôn ngữ của quý vị miễn phí. Để yêu cầu được hông dịch viên giúp đỡ, vui lòng gọi số điện hoại miễn phí dành cho hội viên được nêu rên hẻ ID chương rình bảo hiểm y ế của quý vị, bấm số (866) TTY 711 您有權利免費以您的母語得到幫助和訊息 洽詢一位翻譯員, 請撥打您健保計劃會員卡上的免付費會員電話號碼, 再按 (866) 聽力語言殘障服務專線 711 귀하는도움과정보를귀하의언어로비용부담없이얻을수있는권리가있습니다. 통역사를요청하기위해서는귀하의플랜 ID 카드에기재된무료회원전화번호로전화하여 (866) 번을누르십시오. TTY 711 مقرب لصتا يروف مجرتم بلطل.ةفلكت يأ لمحت نود كتغلب تامولعملاو ةدعاسملا ىلع لوصحلا يف قحلا كل ىلع طغضاو ةيحصلا كتطخب ةصاخلا ةيوضعلا ف رع م ةقاطبب جردملا ءاضعألاب صاخلا يناجملا فتاهلا (TTY) 711 يصنلا فتاهلا (866) یرف لوٹ ےئل ےک ےنرک تاب ےس نامجرت یسک ےہ قح اک ےنرک لصاح تامولعم روا ددم تفم ںیم نابز ینپا وک پآ TTY 711 ںیئابد (866) ےہ جرد رپ ڈراک یڈ یئآ نالپ ھتلیہ ےک پآ وج ںیرک لاک رپ ربمن نوف ربمم May karapaan kang makaanggap ng ulong a impormasyon sa iyong wika nang walang bayad. Upang humiling ng agasalin, awagan ang oll-free na numero ng elepono na nakalagay sa iyong ID card ng planong pangkalusugan, pinduin ang (866) TTY 711 Vous avez le droi d obenir grauiemen de l aide e des renseignemens dans vore langue. Pour demander à parler à un inerprèe, appelez le numéro de éléphone sans frais figuran sur vore care d affilié du régime de soins de sané e appuyez sur la ouche (866) ATS 711. आप क प स अपन भ ष म सह यत एव ज नक र न :श ल क प र प त करन क अध क र ह द भ ष ए क ल ए अन र ध करन क ल ए, अपन ह ल थ प ल न ID क र ड पर स च बद ध ट ल-फ र न बर पर फ न कर, (866) दब ए TTY 711 اب یهافش مجرتم تساوخرد یارب.دییامن تفایرد ناگیار روط هب ار دوخ نابز هب تاعالطا و کمک هک دیراد قح امش ار (866) و هدومن لصاح سامت دوخ یتشادهب همانرب ییاسانش تراک رد هدش دیق ناگیار نفلت هرامش TTY 711.دیهد راشف Sie haben das Rech, kosenlose Hilfe und Informaionen in Ihrer Sprache zu erhalen. Um einen Dolmescher anzufordern, rufen Sie die gebührenfreie Nummer auf Ihrer Krankenversicherungskare an und drücken Sie die (866) TTY 711 તમન વ ન મ લ ય મદદ અન તમ ર ભ ષ મ મ હ ત મ ળવવ ન અધ ક ર છ. દ ભ ષ ય મ ટ વ ન ત કરવ, તમ ર હ લ થ પ લ ન ID ક ર ડ પરન સ ચ મ આપ લ ટ લ-ફ ર મ મ બર ફ ન ન બર ઉપર ક લ કર, (866) દબ વ. TTY 711 Вы имеете право на бесплатное получение помощи и информации на вашем языке. Чтобы подать запрос переводчика позвоните по бесплатному номеру телефона, указанному на обратной стороне вашей идентификационной карты и нажмите (866) Линия TTY 711 ご希望の言語でサポートを受けたり 情報を入手したりすることができます 料金はかかりません 通訳をご希望の場合は 医療プランの ID カードに記載されているメンバー用のフリーダイヤルまでお電話の上 (866) を押してください T T Y 専用番号は 711 です ທ ານມ ສ ດທ ຈະໄດ ຮ ບການຊ ວຍເຫ ອແລະຂ ມ ນຂ າວສານທ ເປ ນ ພາສາຂອງທ ານບ ມ ຄ າໃຊ ຈ າຍ. ເພ ອຂ ຮ ອງນາຍພາສາ,ໂທຟຣ ຫາຫມາຍເລກໂ ທລະສ ບສຳລ ບ ສະມາຊ ກທ ໄດ ລະບ ໄວ ໃນບ ດສະມາຊ ກຂອງທ ານ,ກ ດເລກ (866) TTY 711

17 TO LEARN MORE ABOUT YOUR BENEFITS, TOOLS AND RESOURCES: Visi your personal online accoun a or he HealhSelec websie a Call he HealhSelec Cusomer Care Team oll-free a (866) (TTY 711), 8 a.m. 7 p.m. CT, Monday Friday and 7 a.m. 3 p.m. CT on Saurday. Adminisraive services provided by Unied HealhCare Services, Inc. or heir affiliaes. Real Appeal is a volunary weigh loss program ha is offered o eligible paricipans as par of heir benefi plan. The informaion provided under his program is for general informaional purposes only and is no inended o be nor should be consrued as medical and/or nuriional advice. Paricipans should consul an appropriae healh care professional o deermine wha may be righ for hem. Any iems/ools ha are provided may be axable and paricipans should consul an appropriae ax professional o deermine any ax obligaions hey may have from receiving iems/ools under he program. Virual visis are no an insurance produc, healh care provider or a healh plan. Unless oherwise required, benefis are available only when services are delivered hrough a Designaed Virual Nework Provider. Virual visis are no inended o address emergency or life-hreaening medical condiions and should no be used in hose circumsances. Services may no be available a all imes or in all locaions. Advocae services should no be used for emergency or urgen care needs. In an emergency, call 911 or go o he neares emergency room. The informaion provided hrough Advocae (Advocae4Me) services is for informaional purposes only and provided as par of your healh plan. Wellness nurses, coaches and oher represenaives canno diagnose problems or recommend reamen and are no a subsiue for your docor s care. Your healh informaion is kep confidenial in accordance wih he law. Advocae services are no an insurance program and may be disconinued a any ime. Rally Healh provides healh and well-being informaion and suppor as par of your healh plan. I does no provide medical advice or oher healh services, and is no a subsiue for your docor s care. If you have specific healh care needs, consul an appropriae healh care professional. Paricipaion in he healh survey is volunary. Your responses will be kep confidenial in accordance wih he law and will only be used o provide healh and wellness recommendaions or conduc oher plan aciviies. The informaion provided hrough hese programs is for educaional purposes only as a par of your healh plan and is no a subsiue for your docor s care. Please discuss wih your docor how he informaion provided is righ for you. Your personal healh informaion is kep privae in accordance wih your plan s privacy policy. The Healhy Pregnancy Program follows naional pracice sandards from he Insiue for Clinical Sysems Improvemen. The Healhy Pregnancy Program can no diagnose problems or recommend specific reamen. The informaion provided is no a subsiue for your docor s care. For a complee descripion of he UniedHealh Premium Designaion program, including deails on he mehodology used, geographic availabiliy, program limiaions and medical specialies paricipaing, please see myuhc.com/hs. Disease Managemen programs and services may vary on a locaion-by-locaion basis and are subjec o change wih wrien noice. UniedHealhcare does no guaranee availabiliy of programs in all service areas and provider paricipaion may vary. Cerain iems may be excluded from coverage and oher requiremens or resricions may apply. If you selec a new provider or are assigned o a provider who does no paricipae in he Disease Managemen program, your paricipaion in he program will be erminaed. Disclosure: The Healh Discoun Program is adminisered by HealhAllies, Inc., a discoun medical plan organizaion. The Healh Discoun Program is NOT insurance. The discoun program provides discouns a cerain healh care providers for medical services. The discoun program does no make paymens direcly o he providers of medical services. The discoun program member is obligaed o pay for all healh care services bu will receive a discoun from hose healh care providers who have conraced wih he discoun plan organizaion. HealhAllies, Inc., is locaed a P.O. Box 10340, Glendale, CA, 91209, , ohacusomercare@opumhealh.com. The healh discoun program is offered o exising members of cerain producs underwrien or provided by UniedHealhcare Insurance Company or is affiliaes o provide specific discouns and o encourage paricipaion in wellness programs. Healh care professional availabiliy for cerain services may be dependen on licensure, scope of pracice resricions or oher requiremens in he sae. UniedHealhcare does no endorse or guaranee healh producs/services available hrough he discoun program. This program may no be available in all saes or for all groups. Componens subjec o change. NOTE: ERS canno and does no guaranee he lengh of ime ha a specific or ype of value-added produc will be offered or ha a produc will be offered in he fuure. If you have quesions or concerns abou hese producs, please conac UniedHealhcare direcly. All rademarks are he propery of heir respecive owners. 17

18 KEY HEALTHSELECT CONTACT INFORMATION HealhSelec Websie Personal Online Accoun HealhSelec Cusomer Care (866) (TTY 711) 24/7 Nurse Access (866) (say speak wih a nurse ) Healhy Pregnancy (888) Prescripion Drug Program Caremark (hrough December 31, 2016) (888) HealhSelec Cusomer Care (beginning January 1, 2017) (866) (TTY 711) /16